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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page of L <br /> TYPE OF ACTION Q,.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- I' 7.PERMANENTLY CLOSED SITE <br /> (Check one dem only) r 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 D <br /> F 6 TEMPORARY SITE CLOSURE 11 <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doi Business As) 3 FACILITY ID <br /> Loy�s Cut,L, r S�,-� � ?,,2 3 6 /,)-474 <br /> NEAREST CROSS STREET 401 1 ^ /F���CILITY OWNER TYPE r 4 LOCAL AGENCY/DISTRICT- <br /> SA <br /> GENCY/DISTRICT' <br /> $t• Cory e� o� Jti_k T <br /> �P S4r.I�S '(� 81. CORPORATION r 5 COUNTY AGENCY' <br /> BUSINESS TYPE 1.GAS STATION r- 3 FARM h 5.COMMERCIAL r 2. INDIVIDUAL h 6 STATE AGENCY' <br /> F 2.DISTRIBUTOR r 4.PROCESSOR F6 OTHER r 3. PARTNERSHIP F 7 FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency.name of supervisor of <br /> REMAINING AT SITE trustlands� division,section or office which operates the UST <br /> (This is the contact person for the tank records.) <br /> 404 �;v r Yes @No 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> P ONE 408 <br /> PROPERTY OWNER NAME 407 �o�) 3 8'�- 0 9?3 <br /> L Civil <br /> Co�,►,�I. S���s o� Cwt; �o,.k�c, <br /> M ING OR STREET ADDRESS i <br /> '1 409 <br /> STATE 411 ZIP C412 <br /> CITY 410 0 1 nODE 3 I Z <br /> OICIo l�owa Lt� '` <br /> PROPERTY OWNER TYPE I- 2, INDIVIDUAL I' 4. LOCAL AGENCY/DISTRICT I- 6 STATE AGENCY 413 <br /> ©1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY I- 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION =PUE <br /> TANK OWNER NAME 414 t (� kl 35P�- 9 F3 <br /> Lw _'s C () +v 5 ,.�1 0 CSI AV <br /> M ING OR S/J({�EET ADDRESS 16 <br /> m O, IJ CX �O� TATE 418 ZIP CODE 419 <br /> cITY 417 0KIC.ko 01( '131Z�o <br /> TANK OWNER TYPE r 2. INDIVIDUAL I' 4. LOCAL AGENCY I DISTRICT I� 6. STATE AGENCY 420 <br /> Q1 CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY h 7 FEDERAL AGENCY <br /> ;:nitAi 17AIInN IMI STORAGE FEE <br /> TY:(T:K):H7Q 4 4 <br /> Call(916)322-9669 if questions arise 421 <br /> V PF INDICATE METHODS) T 7. STATE FUND I, 10. LOCAL GOV=T MECHANISM <br /> I 1 SELF-INSURED r 4 SURETY BOND <br /> I 1'9 STATE FUND d CFO LETTER I 99 OTHER <br /> 2 GUARANTEE r 5. LETTER OF CREDIT 422 <br /> 3. INSURANCE I-6. EXEMPTION 1 9. STATE FUND S CO <br /> Check one boa to indicate which address should be used for bqa <br /> I notifications and mailirq. r 1. FACILITY I' 2, PROPERTY OWNER 3. TANK OWNER 423 <br /> Che:noldi tions and marlin wd t t h t nk unbss 1 or i <br /> TIIEtF <br /> Certification I certify that the information provided herein is true and accurate to the best of my kr ledge. 424 HONE (/ 425 <br /> SI NATLL OF PLIfANT_ V 3 DATE q�.�.t O�,'�� f O <br /> �0 // <br /> NAMMF PLICA T(p t) 426 �{.Y 01 <br /> J T ENV 427 <br /> �S <br /> ,� C f< e v <br /> STATE US7 FACILITY NUMBER(For local e 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> 5 Fomidrly SWRCS Form A <br /> UPCF(1/99 revised) <br />